Role of the School Nurse

There is an increasing number of students entering schools with chronic health conditions that need management within the school day. The school nurse serves in a vital role that bridges health care and education. The nurse supports student success by providing health care through assessment, intervention, and follow-up through a school setting. The nurse must be able to provide services while maintaining standards of practice in an ever-changing society. The nurse has to address the ‘physical, emotional, social, and mental health care needs of the students. The nurse serves to enhance student’s health, safety and capacity for learning. Certified School Nurse (CSN), Heather Hardy, identifies the different roles and responsibilities of the nurse through this interview.

School Nurse Role

The role of the school nurse is to link healthcare and educational goals. The schedule for the school nurse form day to day varies. Different situations may arise that have to be handled in the morning or before the end of the day. A typical day could start from a student coming to the office with complaints of not feeling well or a parent calling stating that their child had head lice. The nurse’s daily schedule depends on the needs of the student and their medication administration times. Similar to a hospital, events occur that need to be prioritized daily.  These occurrences can be anything from a severe injury to a student having an asthma attack,  another student frequenting the nurse that may need counseling. Nursing is not all band-aids and ice packs.

Nurse Hardy has the responsibility of two elementary schools. One school has 312 students to one nurse and the other has 368 students to one nurse.  A nurse legally can be responsible for up to 1500 students. The immediate supervisor to the CSN’s is the Supervisor of Student Services and the school Principal.

The CSN is evaluated separately by the Principal and Supervisor of Pupil Services.  A rubric is used from the Pennsylvania Department of Education and the assessment is for the Certified School Nurse. The nurse is assessed in areas that are not appropriate for a principal with no medical background to evaluate. The nurse is evaluated on the knowledge of the nursing process, individual health needs, establishing a culture of health and wellness, and promoting a safe and healthy environment. The nurse states that this is done annually, with the same results every year. The National Association of School Nurses (NASN) states that supervision and evaluation should be provided by clinical and administrative supervision. The nurse is responsible for ensuring that their practice meets standards for safety and is based on evidence-based practice (EBP) or best practice (ANA & NASN, 2017). Someone with clinical knowledge and skills to enhance and promote the professional growth of the school nurse. Only 36.2% of school nurses report that they are supervised by a registered nurse (Mangena & Maughan, 2015). The goal of the evaluation process is to verify competence and promote the nurse to reach their highest potential. Peer evaluations would be beneficial in promoting the growth of the school nurses in this district.

Nurse Hardy has previous hospital and community experience. Starting at a well-child clinic out of college in the state of Kentucky.  After the clinic, she worked as a Mother/Baby nurse and then a pediatric floor nurse. Working with the community, new mothers, and pediatrics made her want to become a school nurse.  Starting a family of her own, she realized that school nursing would enable more time with her family.  While working in a school health clinic she pursued a certificate in school nursing. Being a CSN for five years has allowed her to spend more time with her children and family. The schedule is conducive to her children’s busy schedules and she cannot see herself in any other nursing role. 

School nurse collaboration with faculty/staff

The school nurse must possess effective communication skills to build respect and rapport among faculty and the community. The nurse’s roles have expanded to include acting as advocates for children’s health care, counseling children, and educating the community about health concerns. The nurse is involved with the medical and safety component of Individualized Education Plans (IEP), Student Assistance Program (SAP), and 504 plans. Any safety concerns for students would be addressed by the CSN. The management of chronic health conditions takes place under the leadership of the school nurse. The nurse creates individualized emergency and healthcare plans for students. The nurse will educate the school health team to implement and delegate nursing care when appropriate by law (Duff, 2014). Education to staff on the administration of an Epi-pen is an example of appropriate delegation. The nurse is involved as needed with IEPs and SAP at the elementary level in this school district. Regularly scheduled meetings or SAP, take place to discuss students in need of financial assistance, screenings results, medical neglect, chronic illness, and students with psychosomatic concerns. Nurse Hardy attends middle and high school meetings weekly and is updated on the concerns in the elementary buildings.

The nurse collaborates with everyone from the principal, teachers, school counselors, custodians, and parents. Interdisciplinary teams rely on the overlapping knowledge, skills, and abilities of each professional member to enhance student health outcomes (Maughan, Bobo, & Schantz, 2016). The nurse must collaborate with staff as needed on student care and education of allergies and reactions, epi-pen training, first-aid and basic life support (BLS). The nurse must alert the teacher if there is a health condition that may affect the students’ ability in the classroom, such as diabetes management. The nurse also needs to communicate with a teacher if a student had frequent visits to the health office and to assess how the student appears in class. Students will frequent the nurse’s office from other classrooms, such as specials or the lunchroom. Communicating with the teacher is beneficial because they are the ones that are with the students the majority of the day. Nurse also communicate with special education and support staff.  The nurse may consult on medical or medication needs.  Behavior is discussed whether a student may be under or over medicated. Toileting issues, illnesses, and injuries are among other matters the nurse must discuss with teachers and the students’ parents or guardians.

The nurse needs to build rapport and trust with the parents and guardians. Nurses do not communicate regularly with all family members, but it is important that they feel safe while their children are in the care of the nurse. Whether the child has severe allergies, a chronic condition, or they have an injury, the nurse must communicate with these families. There are times throughout the year that the nurse will have to send letters home with health screening results, referrals, and request mandated dental and physical forms.  The nurse may need to guide families in obtaining health care coverage for their child or make them aware of community services that are available to them.

The school nurses continue to decrease the number of days and the frequency with which students are absent due to illness with education to families and assessment skills. The nurse must collaborate with the attendance officer to check in on students that have been absent or are absent frequently. Typically, if a student is absent for three days the nurse will call to see if the family needs any guidance or has any questions. Ensuring that the student is safe and receiving appropriate treatment as needed. The nurse may need to assist families with references to seek care or collaborate with the school counselor on behavioral or social issues.

The nurse and student counselor work together daily. These professionals overlap interaction with the same students prompting the need for effective collaboration. Discussing students with hygiene issues, somatic complaints from stress, abuse, sexual activity and pregnancy (Grubbs, Muro, & Clements, 2016). Working together, a counselor and nurse can provide a safe and unprejudiced environment in which students can receive necessary support and intervention (Grubbs et al., 2016). They will assist with students’ frequent health office visits, medical crisis, anxiety, self-harming, hygiene, attendance, bullying, and educational accommodations. The nurse notifies the counselor of frequent somatic complaints that may be related to social anxiety or need for counseling or assistance with instruction.  Building rapport with students aid in facilitating a trusting relationship to recognize what the student may deal with daily (Grubbs et al., 2016).

The principal and the nurse collaborate to deliver information to families and initiate staff training. Information can be as simple as reminding parents and guardians that there will be outdoor recess and for students to dress appropriately for the occasion. There are times when a student reports bullying or a physical altercation to the nurse, they must inform the principal. An open door of communication is necessary to aid in the families feeling that their children are in safe and caring hands. The nurse will facilitate trainings such as BLS, first-aid, and how to administer lifesaving medication. The principal and the nurse will collaborate on how to best deliver and make sure that all staff is in attendance. Any time an incident has escalated, the nurse will make the principal aware first.

Cleaning needs need to be reported to the custodial staff. It is important to make them aware of communicable diseases and whether a classroom needs to be cleaned thoroughly. They must be aware if there is vomit, blood, or urine that needs to be cleaned. They also would need to know if lice were present in a room and they can take measures to clean carpet and toys appropriately.  Our school has a designated nut-free table at lunch that is maintained to eliminate the occurrence of an allergic reaction. Collaboration does not stop here, the nurse has to communicate with food services as well.

Collaborating with food services can be just as important to maintain the health and safety of the students. Food services must be aware of dietary restrictions and food allergies. The nurses may need to obtain nutritional facts for diabetic students in managing insulin administration and counseling a student about healthy food choices.  Foodservice assists to maintain a nut-free table to avoid anaphylaxis from cross-contamination of other students’ lunches. The nurse would notify dietary and the students’ teachers of necessary accommodations.

School health program/population

 The Pennsylvania Public School Code requires certain school health services for all children of school age (DOH, 2019). Health services, physical exams, dental exams, vision screenings, hearing screenings, growth screenings, scoliosis screenings, TB, and lead testing are among these mandated screenings.The assessment of student health care needs, development of plans of care, medication administration, first aid, and emergency care is provided daily throughout the school district (DOH, 2019).Mandated school health screenings enable early identification of health conditions and the prevention of more serious health issues.  Screenings provide an opportunity to support students’ health through education and referrals to providers when they are conducted at regular periods (Resha & Taliaferro, 2017). Hearing, vision, and growth screenings are required at regular intervals in public school districts (Dean, Kindermann, Carson, Gavin, Frerking, & Bergren, 2014). These screenings are not intended to diagnose and do not take place of regular health care needs. Hearing screenings are administered in kindergarten through third grade, then again in seventh and eleventh grades. Vision and growth screenings are provided from kindergarten through twelfth grade. First graders are also screened with a convex lens test. Color vision test and depth perception can be screened in first or second grades. The CSN in my district screen color vision in kindergarten, convex lens in first grade, and depth perception in second grade.  Students that receive special education services are to receive screenings and exams according to grade level on their IEP (DOH, 2019). Scoliosis screenings are completed in sixth, seventh, and eleventh grades. If the student had a scoliosis screening on their sixth grade physical exam it may be used in place of screening (DOH, 2019). A referral is made for the student if they do not pass an initial assessment and the repeat screening by another nurse (Dean et al., 2014).  Referrals should be sent home in a sealed envelope, a second letter may be sent as a reminder about six weeks later as a reminder to the parent to seek further evaluation by a physician.

Immunization assessment, dental and physical exams are other mandated screening that is required for entry into school, kindergarten and or first grade. The nurse has to make sure that the appropriate immunization schedule was followed and the students are up to date on their shots. If there are any discrepancies, the parents must provide written documentation from the doctor stating when the student will be administered missing doses. Students will need another physical examination for sixth and eleventh grades. Dental exams are required again in third and seventh grades. Many students do not return their forms or documentation, therefore letters are sent home reminding parents to provide documentation or the student will be evaluated by the school dentist and doctor if necessary. These examinations do not take place of dental cleanings, but the doctor will refer students as necessary for any abnormal findings.

The responsibilities to develop an adequate school health program is to consider federal, state, and local laws, public health standards, and school board policies (Selekman, Shannon, &Yonkaitis, 2019). The nurse must ensure regulations are followed, mandates and referrals for care are prepared. The daily presence of a school nurse will promote an adequate health program. The health office should be viewed as a safe and welcoming place for the students (Selekman et al., 2019). Accurate documentation of all health screenings and referrals are made. The CSN must ensure that appropriate health care is provided for illness and injuries. Correct referrals for health care needs are presented to parents and guardians. The nurse must ensure that appropriate medication orders are received, documented, and administered. Communicating allergies and health concerns to appropriate staff. Staff needs to be aware of medication available to avoid emergent situations or control emergencies. Educating staff members about conditions a student may have to recognize early signs and symptoms of their condition to alert the nurse. Communicating with staff, students, families, and supervisors about ongoing issues or occurrences.

Many challenges arise from caring for English language learners (ELL). Communication with students and their families can be challenging. Educating English Learners (ELS) program is provided by English as a second language (ESL) teacher. This program helps promotes the use of English in social and academic settings. The ESL teacher assists the nurse in communicating with ELS families and translating documents. Another program available is low-cost or free lunches through the National School Lunch Program (NSLP). The majority of our minority students benefit from this program.

 Common problems and concerns for this population arise frequently. The school nurse assists in educating vulnerable populations. Population of poor and immigrant children increasing since 2000, school nurses must be creative with their education delivery to be accessible by the vulnerable populations (Duff, 2014). In Nurse Hardy’s school district there are language and cultural barriers in communication and understanding what a student may need. Conducting screenings for these students can be challenging in interpreting their level of understanding versus having a physical deficit. Communicating with their family can be difficult to ensure follow up with a physician to ensure the child’s needs are met. School nurses can increase care coordination and follow up of vision screenings in low-income communities (Rodriguez, Srivastava, & Landau, 2018). Hardy states that receiving referrals back from parents is a major challenge, “about 2 out of every 10 referrals on average are returned to the health services department” (2019).  Many students referred, especially minorities and children from low socio-economic status, may not receive the care they need. Reasons being parents unaware of results, parental lack of understanding, lack of clarity in communicating results, lack of insurance, lack of transportation, and mistrust of the school nurse (Rodrigues et al., 2018). Lack of resources available, lack of motivation and communication from a school nurse can impede the success of follow up care.

Another area of concern for this population is sending their children to school with a fever or communicable disease and the effect it can have on other students. Most times their parents are looking to the nurse for guidance on whether or not the child should be seen by a doctor or use health services as their primary care. Nurse Hardy said a student came to school in an air cast without the ability to walk. The student was seen by a doctor but if the parent was understanding of instructions they would have given her an analgesic to assist with initial pain to enable their child with ambulating. The nurse has to respect cultural differences while promoting health and safety to students at all times. Another issue is transportation, the working parent may drive while the other parent stays home, but has no means of transportation to pick up their ill child. There are times when the student will rest in the health office all day and have to return home on the school bus. 

Children with complex health care needs and intellectual and developmental disabilities are on the rise due to advances in medical technology (Singer, 2013). These students are entering an inclusive school setting and nurses feel ill-prepared to care for these students. Lack of education and experience of children with disabilities is a common concern (Singer, 2013). Individuals with Disabilities Act (IDEA) enables children with disabilities to be educated in the least restrictive environment along with their peers (Singer, 2013). Challenges faced by school nurses include assessing students who have rare disorders, providing care to students who have wide ranges of needs within their disability, working with culturally diverse disabled students, and parents who do not fully inform the school nurse of their child’s condition (Singer, 2013). Students with intellectual disabilities (ID) and students with commination disorders may not articulate their needs. Effective communication promotes better patient outcomes and good nursing care (Singer, 2013). Nurse Hardy expressed a lack of resources and technology to communicate with these students is hindering their care. School nurses could benefit from tools to increase their ability to conduct accurate health assessments and screenings on students with intellectual and developmental disabilities (Singer, 2013).

Under IDEA these students are eligible for special education with an Individualized Education Program (IEP), Section 504 Accommodation Plans, an Individualized Healthcare Plan (IHP), and Emergency Action Plans (EAP) to outline how their needs will be met (Selekman, 2019, 607). Services provided to these students under IDEA are; speech-language pathology, psychology services, audiology services, physical and occupational therapy, counseling services, transportation, social services, school nursing services, diagnostic services, and parent counseling and training (Selekman, 2019, 161).

Identified concerns of the school nurse

 Students today are facing family crises, poverty, homelessness, and violence, which increase their mental and physical health needs. The school nursing role is changing with the demands in caring for chronically ill and medically fragile students. There are a growing number of students with asthma, diabetes, life-threatening allergies, seizure disorders, and obesity. Representing only a fraction of health concerns, nurses must increase their knowledge and specialized skills to provide for the student population. Another issue is the number of unvaccinated students and noncompliance. Vaccination compliance is a challenge not only when vaccines are not received, but when pediatricians are administering medication to early. Depending on the vaccine there is a grace period in which the pediatricians are not compliant. This poses a problem for the nurse in receiving proper documentation from the student’s family stating that no additional medication is needed. This can affect reimbursement from the state that the school will receive.

 The use of social media is another concern for the school nurse. Social media can negatively affect the mental health of adolescents. Social media can expose students to bullying, cyberbullying, and poor self-image which can create social anxiety a poor self-image (Cantone et al., 2015 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378064/).

 *Nurse Hardy feels that her role as a nurse is changing in the

 Belonging to the NASN has been beneficial in improving her role as a CSN. Available to members are online continuing nursing education (CNE) certificates, conferences and workshops, e-learning tools, and training tools. Members have access to nursing journals and publications. She also recommends attending a nursing conference relevant to school nursing and community health. 

How will you use this information as you embark on a career as a Certified School Nurse?

 All that I have learned from this interview and being a health aide will prepare me to better assist the community and student population. As a CSN I will become a lifelong learner through advancing my education and joining the National Association of School Nurses (NASN). Staying current with trends and evidence-based practice will assist in educating staff, students and their families, and better serving the community.

References

• American Nurses Association & National Association of School Nurses. (2017). School nursing: Scope and standards of practice (3rd ed.). Silver Spring, MD: Author.
• *Bergren, M.D., (2017) School nursing and population health: Past, present, and Future. OJIN: The Online Journal of Issues in Nursing (22)3. doi:10.3912/OJIN.Vol22No03Man03
• Dean, B. B., Kindermann, S. L., Carson, T., Gavin, J., Frerking, M., & Bergren, M. D. (2014). Healthe kids: An assessment of program performance and participation. Journal of School Nursing, 30(6), 430–439. https://doi.org/10.1177/1059840514527622
• Department of Health. (2019). Mandated school health program. Retrieved on November 11, 2019 from https://www.health.pa.gov/topics/school/Pages/Mandated-School-Health-Programs.aspx
• Duff, C. L. (2014). School nurses-New roles for better outcomes. NASN School Nurse, 29(5), 216-217. Retrieved from https://journals-sagepub-com.proxy-sru.klnpa.org/doi/pdf/10.1177/1942602X14545970
• Maughan, E., Bobo, N., Butler, S., & Schantz, S. (2016). Framework for 21st century school nursing practice: National Association of School Nurses. NASN School Nurse, 31(1), 45–53. https://doi.org/10.1177/1942602X15618644
• Grubbs, L., Muro, J. H., & Clements, K. (2016). School counselors and nurses: Collaborative best practices for maintaining confidentiality with pregnant adolescents. The Practitioner Scholar: Journal of Counseling and Professional Psychology, 5, 20-29. Retrieved from https://pdfs.semanticscholar.org/582f/f06b141b2c96fee8f9fb3ce339a8e136f115.pdf
• Mangena, A. S., & Maughan, E. (2015). The 2015 NASN school nurse survey: Developing and providing leadership to advance school nursing practice. NASN School Nurse, 30(6), 328-335. doi: 10.1177/1942602X15608183 https://doi.org/10.1177/1942602X15608183
• Resha & Taliaferro. (2014) Legal resources for school health services
• Rodriguez, E., Srivastava, A., & Landau, M. (2018). Increasing screening follow-up for vulnerable children: A partnership with school nurses. International Journal Of Environmental Research And Public Health, 15(8). https://doi.org/10.3390/ijerph15081572 http://web.b.ebscohost.com.proxy-sru.klnpa.org/ehost/detail/detail?vid=0&sid=b9ef00d1-9337-4413-bf5c-35ae19426896%40pdc-v-sessmgr05&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#AN=30044383&db=mdc
• Singer, B. (2013). Perceptions of school nurses in the care of students with disabilities. The Journal of School Nursing, 29(5), 329–336. https://doi.org/10.1177/1059840512462402